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APPLICATION FOR SANITATION PERMIT Permit No.=_-'t_.-"�jl_ w . (Complete in Duplicate) :`/ -1 a Date Issued a Applica+ion is hereby made to the San Joaquin Local Health Distri t for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance N 549. JOB ADDRESS AND LOC TIO. -----.---_ � _,.._. !.r - -%/�.------•---------_ - ----------------------------------------------------------- rt ------------------------ ------ Phone. Owners Name---- -fi--- -•---E--- - ••-------- -----•------------------ ------------- Address ------------- -------------------------- Contractor's Name_ ---------1�------- � I Phone. Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Motel ] Other ❑ Number.ofeliving units: _--• __ Number of bedrooms ...1__ Number of baths J___ Lot size ____. d 1v_fl___-___--_____"_"_______-- - Water Supply:, Public system Community system ❑ Private ❑ Depth to Water Table Aft. R Character of soil to a depth of 3 feet: Sand [:] Gravel E] Sandy Loam ElClay Loam E] Clay [:] obe AdHardpan ❑ Previous Application Made: Yes ❑ No New Construction: Ye No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �+ Septic Ta k: k s Distance from nearest well-----------------Distance from foundation_______________-__.Materiai___--______.-________________________________- > No. of compartments--- -------=--------------Size--------- ---------------------Liquid depth---------- ---------------Capacity.----- -- •---------- r .Disposal'F'el : ' Distance from nearest we!!_________________Distance from foundation--------------------Distance to nearest lot line-_--.--_----____- 1i Number of lines-----------------------------------Length.of`each line------------------------------ Width of trench----------------------------------- Type of filter material'___________________I-____Dept h of filter material-----------------------Total length______--___--_-_______________"_"_______ Seepage Pit: Distance to nearest well_— ___Distance f m fou$dation__= ._-_'_`Dista ce to nearest lot;line_______________— ` Number ofdpits____ ______________Lining materia. _ Size: Diameter____� ��-____Depth_.-. _____-._._____ $_ -_� - .... Cesspool: Distance from nearest+well_________________Distance from foundation-----------.__.__,__.Lining material-_.j_____________. ❑ Size: Diameter 3 Dept Liquid Ca acity----------- ----- ---- gals. 0 Privy: Distance from nearest well________________________'-----------------------Distance from nearest*building----------------- ____________-____----- ❑ Distance to nearest lot line ' f -----------° Remod li nd/or re_airing.(describe): .... ��x � F��' „c - f _.. r ------------------------------------------------------- ------ --- ry • f --- , --------------_•_- ----------------------v -----------------------------••-•--•------------------------------.......---- -•--•____------------- -------------•---'------- �r 1 a � F _____________________r__--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- . I hereby certify that I have prepared this application and that the work will be done in accordance with San JoBquin.County ordinances, StbtWa -andules and regulations of the San Joaquin Local Health District.Si ned - - ' f -- ----�------------- -----------------------------"---------- --------(Owner end or Contractor) 9 } tBy----------- ------(Title-- - ��-------- - - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be ed on reverse si FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY-----W -------------- / ------------ ------------------------------------ DATE------- 3 REVIEWEDBY ------------------------------------------------------------------------- DATE. BUILDINGPERMIT ISSUED r -----•-------------------- DATE-----:------------------------------------------------------- Alterations and/or.recommendations:---- - ------- ------------- a y IL Y ____________________________________________________________"___-_-----_-_.-"------_______-__-__-__--____S___-_____"______________--_--__.____-_-______-___-"__-_"_________-__"____________"_"___________"____"__-_____________ _______________________"____________-___-____._-_-____________-____________._____"___________--______------_________________-______"_"__"________-___-------__-..--_-________-______________-_____________________________--__ S __________________________________-__--__--____--_______-._-__---___-__.__-____-___ ______-_--________-__-______--.-____________-_____-___"-__-__________________-___--____-_____-_-_--.-------_-__-_-_______ 1 FINAL INSPECTION BY:------- � �✓ �� ------------ Date------- -------------------�--------- (- z ------ - --------------------------- 'f SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Str of 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California PC,—,?—?M Revised W-2100